DD form A4_Layout 1 12/01/2011 08:19 Page 1 Instruction to your Bank or Building Society Originators Identification to pay Direct Debits 800176 Please fill in the relevant sections of this form and return completed to: Ipswich Building Society PO Box 547 Ipswich IP3 9WZ Name(s) of account holder(s) Reference Number (Ipswich Building Society main mortgage account number) For Ipswich Building Society Office Use Only Bank or Building Society account number Branch sort code Instruction to your Bank or Building Society Please pay Ipswich Building Society Direct Debits from the account detailed on this instruction subject to the safeguards assured by The Direct Debit Guarantee. Name and full postal address of your Bank I understand that this instruction may remain with Ipswich Building Society and, or Building Society Branch if so, details will be passed electronically to my Bank/Building Society. To: The Manager __________________________ Bank or Building Society Signature(s) Address _________________________________________________________ 1 ________________________________________________________ _________________________________________________________________ _________________________________________________________________ 2 ________________________________________________________ ________________________________ Postcode ________________________ Date Banks and Building Societies may not accept Direct Debit Instructions for some types of account STANDING ORDER CANCELLATION Name and full postal address of your Bank or Building Society Branch To: The Manager __________________________ Bank or Building Society Branch sort code Address _________________________________________________________ _________________________________________________________________ _________________________________________________________________ Bank or Building Society account number ________________________________ Postcode ________________________ Please cancel my/our Standing Order authority to Ipswich Building Society under Reference Number(s) With effect Signature(s) from the last day of Name(s) of account holder(s) 1 ________________________________________________________ 2 ________________________________________________________ Date THIS GUARANTEE SHOULD BE DETACHED AND RETAINED BY THE PAYER • This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits • If there are any changes to the amount, date or frequency of your Direct Debit Ipswich Building Society will notify you 7 working days in advance of your account being debited or as otherwise agreed. If you request Ipswich Building Society to collect a payment, confirmation of the amount and date will be given to you at the time of the request • If an error is made in the payment of your Direct Debit by Ipswich Building Society or your bank or building society you are entitled to a full and immediate refund of the amount paid from your bank or building society • If you receive a refund you are not entitled to, you must pay it back when Ipswich Building Society asks you to • You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us. DDL3.